The Learning Center Preschool Daycare Boca Raton, FL, 33432. , Best Daycare

GENERAL INFORMATION

Custody Documents on File

Yes

CONSENT INFORMATION

1. TRANSPORTATION

I give consent for my child to be transported and supervised by the operation's employees:

for emergency care

on field trips

to and from home

to and from school

2. FIELD TRIPS

I give consent for my child to participate in field trips. I do not give consent for my child to participate in field trips.

3. WATER ACTIVITIES

I give consent for my child to participate in the following water activities:

water table play sprinkler play splashing/wading pools swimming pools aquatic playgrounds

4. RECEIPT OF WRITTEN OPERATIONAL POLICIES

I acknowledge receipt of the facility's operational policies, including those for:

Discipline and guidance

Procedures for release of children

Suspension and expulsion

Illness and exclusion criteria

Emergency plans

Procedures for dispensing medications

Procedures for conducting health checks

Immunization requirements for children

Safe sleep

Meals and food service practices

Procedures for parents to discuss concerns with the director

Procedures to visit the center without securing prior approval

Procedures for parents to participate in operation activities

Procedures for parents to contact Child Care Licensing, DFPS, Child Abuse Hotline, and DFPS website

5. MEALS

I understand that the following meals will be served to my child while in care:

None Breakfast Morning snack Lunch Afternoon snack Supper Evening snack

6. DAYS AND TIMES IN CARE

My child is normally in care on the following days and times:

Day of the Week	AM	PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

CHILD'S ADDITIONAL INFORMATION SECTION

List any special needs that your child may have, such as environmental allergies, food intolerances, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for longterm continuous use, and any other information which caregivers should be aware of:

Does your child have diagnosed food allergies?

Yes

Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

SCHOOL AGE CHILDREN

My child attends the following school

My child has permission to (check all that apply):

walk to or from school or home

ride a bus

be released to the care of his/her sibling under 18 years old

ADMISSION REQUIREMENT

If your child does not attend pre-kindergarten or school away from the child care operation, one of the following must be presented when your child is admitted to the child care operation or within one week of admission Please check only one option:

HEALTH CARE PROFESSIONAL'S STATEMENT: I have examined the above named child within the past year and find that he or she is able to take part in the day care program.

A signed and dated copy of a health care professional's statement is attached.

Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization,which I adhere to or am a member of. I have attached a signed and dated affidavit stating this.

My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and submit it to the child care operation.

REQUIREMENTS FOR EXCLUSION

I have attached a signed and dated affidavit stating that I decline immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized.

I have attached a signed and dated affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination that I am an adherent or member of.

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HEARING EXAM RESULTS

Ear	1000 Hz	2000 Hz	4000 Hz	Pass or Fail
Right				Pass Fail
Left				Pass Fail

VACCINE INFORMATION

The following vaccines require multiple doses over time. Please provide the date your child received each dose.

Vaccine	Vaccine Schedule	Dates Child Received Vaccine
Hepatitis B	Birth (first dose) 1–2 months (second dose) 6–18 months (third dose)
Rotavirus	2 months (first dose) 4 months (second dose) 6 months (third dose)
Diphtheria, Tetanus, Pertussis	2 months (first dose) 4 months (second dose) 6 months (third dose) 15–18 months (fourth dose) 4–6 years (fifth dose)
Haemophilus Influenza Type B	2 months (first dose) 4 months (second dose) 6 months (third dose) 12–15 months (fourth dose)
Pneumococcal	Birth (first dose) 1–2 months (second dose) 6–18 months (third dose) 12–15 months (fourth dose)
Inactivated Poliovirus	Birth (first dose) 1–2 months (second dose) 6–18 months (third dose) 4–6 years (fourth dose)
Influenza	Yearly, starting at 6 months. Two doses given at least four weeks apart are recommended for children who are getting the vaccine for the first time and for some other children in this age group.
Measles, Mumps, Rubella	12–15 months (first dose) 4–6 years (second dose)
Varicella	12–15 months (first dose) 4–6 years (second dose)
Hepatitis A	12–15 months (first dose) The second dose should be given 6 to 18 months after the first dose.

PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

Signature or stamp of a physician or public health personnel verifying immunization information above:

VARICELLA (CHICKENPOX)

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the statement: My child had varicella disease (chickenpox) on or about (date) and does not need varicella vaccine.

ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS

For additional information regarding immunizations, visit the Texas Department of State Health Services’ website at www.dshs.state.tx.us/immunize/public.shtm

TB TEST (IF REQUIRED)

Positive

Negative

GANG FREE ZONE

Under the Texas Penal Code, any area within 1,000 feet of a child care center is a gang-free zone, where criminal offenses related to organized criminal activity are subject to harsher penalties.

PRIVACY STATEMENT

DFPS values your privacy. For more information, read our Privacy and Security Policy online at http://www.dfps.state.tx.us/policies/privacy.asp

SIGNATURES

Child's Parent or Legal Guardian

DAYCARE Enroll

New Parent Forms

GENERAL INFORMATION

CONSENT INFORMATION

1. TRANSPORTATION

2. FIELD TRIPS

3. WATER ACTIVITIES

4. RECEIPT OF WRITTEN OPERATIONAL POLICIES

5. MEALS

6. DAYS AND TIMES IN CARE

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

CHILD'S ADDITIONAL INFORMATION SECTION

SCHOOL AGE CHILDREN

ADMISSION REQUIREMENT

REQUIREMENTS FOR EXCLUSION

HEARING EXAM RESULTS

VACCINE INFORMATION

PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

VARICELLA (CHICKENPOX)

ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS

TB TEST (IF REQUIRED)

GANG FREE ZONE

PRIVACY STATEMENT

SIGNATURES

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DAYCARE Enroll

New Parent Forms

GENERAL INFORMATION

CONSENT INFORMATION

1. TRANSPORTATION

2. FIELD TRIPS

3. WATER ACTIVITIES

4. RECEIPT OF WRITTEN OPERATIONAL POLICIES

5. MEALS

6. DAYS AND TIMES IN CARE

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

CHILD'S ADDITIONAL INFORMATION SECTION

SCHOOL AGE CHILDREN

ADMISSION REQUIREMENT

REQUIREMENTS FOR EXCLUSION

HEARING EXAM RESULTS

VACCINE INFORMATION

PHYSICIAN OR PUBLIC HEALTH PERSONNEL VERIFICATION

VARICELLA (CHICKENPOX)

ADDITIONAL INFORMATION REGARDING IMMUNIZATIONS

TB TEST (IF REQUIRED)

GANG FREE ZONE

PRIVACY STATEMENT

SIGNATURES

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